This is what a DNP does: Change Practice

Work calls attended to. Check. Three-and-a-half-year-old down for his nap. Check. Casserole in the oven for dinner. Check. Let's see... oh yes, time for blogging.

I'm new to blogging, but not quite as new at being a DNP. Back in 2003 when I investigated universities with an interest in pursuing my practice doctorate, there were very few in the nation, and most of them went under the ND (nursing doctorate) nomenclature, now long since forgotten. (The ND now clearly understood by most as the naturopathic degree.) I didn't want to be a researcher, although I've since realized what an exciting option that is for nursing, and if I had another lifetime would unquestionably add that to my educational plan. But I did want to make a difference.

I was in our university's first graduating class of DNPs in 2005. So what does a DNP do? I think the answer is as varied as the degree's essentials, encompassing practice, systems, populations, policy, etc. Among our graduating class, there is a chief wellness officer of a university (the first of its kind), a nurse anesthetist program director (also published author, and in a prior life a VA director), a psychiatric nurse practitioner who helps direct her state's NP organization, a Mayo nursing director, at least two professors, and a college health nurse practitioner. Most of us have published or been part of the sea of change in nursing. We are not an idle bunch. We are about changing things up.

I'm the entrepreneur among us. Prior to my DNP, I had visions of starting a practice that somehow met the needs of the underserved in the community (at a reasonable cost), while also being financially stable and not dependent upon grants. I had seen too many good-hearted nonprofits spend all their time fundraising and grant-writing (I LOVE grant writers, I'm just not one), only to be open for a mere 4 to 8 hours a week, which in my mind made it impossible to provide the kind of continuity of care patients need. I had seen too many for-profit NPs with the heart of a nonprofit find themselves in a distressing state of dissolution after a few years, as Medicaid payments or lack thereof kept them from keeping their doors open long term. Yet I continued to see so many uninsured or underinsured patients fail to get the care they needed, and end up in the ER with a much worse prognosis than if they'd had routine primary care.

I had a lot of ideas about how a hybrid clinic (which would meet the needs of the uninsured, low-income patient AND see insured patients or possibly cash services to stay stable) might work. But it wasn't until I took the time to pursue a DNP that I was able to: 1) evaluate the factors that caused local NP clinics to fail; 2) evaluate the financials and payer mix; 3) look at new models of care; 4) look at consumer perspectives on NP practices; and 5) be a change agent. Gradually it all came together: a unique model of care to meet a local population's need. About 3 years later, as the economy tanked, I went out and opened a little clinic.

And it was the best thing that ever happened to me. I hope it was also a boon to our community. A clinic where people get the kind of care they want and need (you know what I'm talking about if you're an APN: relationship-centered care, use of new technologies, time for evaluating each concern thoroughly, and time for education). And you know what? Even in 2014, ACA or not, there are people (insured or not) looking for a new-fangled, old-fashioned practice like mine.

My professional life consists of clinical practice, managing a business, involvement in professional groups, involvement in political action, publications, education, mentoring ... and yet I still have the control to be able to carve out plenty of play time during the week with the little guy. Now that's a benefit I didn't think of when completing my DNP.

15 comments

I am just completing my DNP, just received my data from my statistician and finishing my Capstone. Besides academia, it has been a real challenge looking for a job! There are no help wanted ads out there for a DNP prepared professional! Help!

I had been an RN for 25 year before going back to college to earn my MNP; I work in a clinic where not only do I see patients who are acutely ill or injured, I specialize in Internal Medicine. The clinic is owned by the hospital corporation that I had worked as an RN. I live in a very small rural community... there are days that I feel so satisfied with my patient care and then there are days that I think to myself "is this all that I'll be doing for the 15 years. I am 50 now and still feel that I want more... I am contemplating going back to college... because as crazy as it sounds, I miss the learning aspect. My husband just glares at me when I speak of college.

I would love to open a clinic in my little town that has nothing - I am well known and have drawn a lot of patients to the clinic in which I currently work.

What to do? What to do? Do I stay with a guaranteed paycheck that does not vary depending on reimbursement or do I jump in with both feet and "swim" like crazy?

I've only been in practice for over a year but wonder if earning my DNP would be something to consider.

I have high aspirations of climbing higher into getting involved with changing healthcare to meet the needs of the community...

I was educated & trained in NM which is independent practice state (collaborating MD of record) & independent practice was promoted. But I moved & practice in TX for 12 yrs. Not independent practice state. Must have supervising/delegating MD. While I am not one of them many of my collegues have opened NP run /managed clinics. And w/o DNPs. My opinion is that RNs, not just NPs, with career goals geared toward research, higher academia or executive positions, will find Ph.d or DNP helpful if not necessary. Many MSNs have Ph.d in other fields. But at level of providing healthcare, I do not find it would add to or change my delivery of evidenced-based care. I do hope & pray that it does not become entry level requirement. This would add to the growing healthcare crisis by decreasing available providers, esp in the underserved.

Cynia, Family/Psych - MSN,RN,FNP/PMHNP-BC

May 31, 2014 1:50 AM

Wichita FallsTX

First of all, in answer to the questions: no you do not have to have a DNP to practice and in some states, like mine you do have to have physician "supervision" even if you have a DNP. You are still a NP. Second, after 17 years of practice, 8 of them serving underserved, I do understand evaluating payor mix, consumer perspectives, and models of care. I looked at opening a practice and decided against it but not because of lack of a DNP. I have been president of our North Texas NP group, have been politically active in advocating for NPs with legislators, and mentored countless students. I haven't published because it's just not in me, but that has nothing to do with my degree. I really still do not know how another non-clinical degree is going to make me better at the care I give. As far as your classmate's roles, many of those could be held with lesser degrees or MBAs. Just not going to go there unless I see a clear benefit other than fitting in with the current trend.

Lesa, FNP

May 30, 2014 5:24 PM

RockwallTX

A doctorate in nursing is not about the title it is about the transformation that takes place in your thinking. I have been a nurse practitioner for many years. What I learned in my DNP program did not change my practice as an NP, it prepared me to ask the harder questions about the care we are giving and it prepared me to lead the research initiatives toward change. The DNP is not about building on the clinical practice of an experienced NP, it is about expanding clinical practice on a scale that directly affects quality care delivery and measurable outcomes. If you cannot understand the enlightenment that accompanies Doctorate education it is probably not for you.

Laurie Ernest, Director, Advanced Practice Nursing, Research, Mag

May 30, 2014 9:46 AM

NY

Kudos to you for opening a clinic for the underserved. I have spent my whole career as an NP (past 17 years) working at a free clinic and I leave everyday knowing that I have made a difference in our patient's lives. I also went back to school even though I am in my 60s because I also believe it is so important for an NP to achieve a terminal degree. I know that this education will help our clinic survive the rapidly changing health care environment.

I just graduated as a FNP, and I was under the impression you cannot own your own practice, besides you always have to have the colaborating Physician which at times seems who is actually owing the practice. Does that change with a DNP., you do not need the collaborating physician anymore? If Medicaid and medicare only pay 85% for services provided by NP's how does that work with when you own the practice. PLease to those practice owners enlight me a bit I'm truly confuced....

Johanna, primary care - new york

May 30, 2014 8:17 AM

new yorkNY

Yes, the dnp is about academia, because a doctor title is a degree that is earned and yet IT IS EARNED. You take a DNP practitioner and compare it to any other practice "doctor" and you will get not only a title, but years of actual "hands" on training that most "doctor" degrees don't even know how to do. The idea of treating patients by what is learned in a book and not utilizing hands on and clinical experiences is why patient care suffers. If you ask most, Nurse practitioners, especially DNPs are the entire package. Its not a matter of "title, Doctor", the reality is that NPs come from a diverse background of experience and actually care (let alone put hands on patients) so calling a DNP, Doctor who ever doesn't matter to us, its a Title, and we are strong enough in our profession that eventually all you will hear about is the strength DNPs provide to health care.

I have my DNP and own my own Primary Care practice and never in a million years would have done anything different. Good luck to all the others out there!

Lisa, dnp - doctor

May 30, 2014 5:27 AM

Here we go again, this continues to be about Academia, many other programs to achieve non floor, or other supervisory roles.

However to have the title of Doctor Aw, now we can beat the garters, and bras, and don't forget the girdles, cause we have the same amount of time to hold the title, but deeinatley not the same training or field.

Please recognize the difference between MD and Ph-d- Ed

CW , practitioner

May 30, 2014 1:03 AM

The post doesn't explain the necessity of the "doctorate" designation. Did you need a doctorate to start your own practice? Was a masters of nursing not sufficient to make this move? Or is this solely for the added credential and the ability of to refer to yourself as Dr. Benedict?

Still confused, as many are I'm sure, what healthcare void is filled by the doctorate degree.

Steve, Family Practice - PA-C

May 29, 2014 11:23 PM

DallasTX

THIS IS NOT A POST----i asked that only my first name be used and my entire name is posted. Pls fix this. Thank you.

Catherine

May 29, 2014 10:49 PM

I do want to start out with saying kudos to you! You have put a lot of hard work into your career without question. I have always wondered about the necessity of the DNP degree. I feel as though I finally don't have to explain what an NP is anymore!! Patients had a hard time understanding the differences between an NP and an MD when I was the first NP they'd encountered. Certainly for those nurses working in education, the DNP is becoming necessary. It is good to hear from Janice, who felt she could practice without the DNP. I am just hoping that its requirement does not become a barrier. Nursing has been through so many levels of professionalism and "titles" historically. I am afraid of this becoming a necessity that does not actually change our role so much.

Catherine Lehan, Endocrine - NP

May 29, 2014 6:48 PM

MA

I started my DNP last fall and have been thrilled at the growth and opportunity that returning to school has provided. After 18years as an acute care NP, I had tunnel vision and was focused only on clinical practice. There is so much more out there for us! APNs are being asked to step into ever more challenging roles as the provision of health care changes in our country and around the world. Nurses need to be prepared with a new world vision and the DNP is offering me that. I have loved every one of my classes and have formed connections that are priceless. Regardless of what you think your professional goals are today, I would advise APNs to start the DNP journey. You don't even realize the opportunities out there until you take a chance and open yourself to the possibilities!

Kathryn Piccolo, Critical Care - ACNP, Cleveland Clinic

May 29, 2014 6:37 PM

ClevelandOH

I spent a lot of time considering a DNP, and decided it wasnt' necessary for my practice. I have a primary care practice x 11 years, and I see as many low income, uninsured as I can afford, to include Medicare and Medicaid. I find that more than a 30% share of Medicare/Medicad/uninsured is all that my practice can afford. Here in Alaska costs are higher, and M/M reimbursement in often less than 1/2 of what we bill. Private practice can be done and done well, without a DNP. The other roles you mention do not fit into a 40-50 h work week, except precepting and some involvement in professional organizations. Glad it works for you.